An organized chronic subdural hematoma in a 74-year-old male patient in a resource-limited setting: case report

Introduction: Organized chronic subdural hematoma (OCSDH) is exceedingly rare, and the diagnosis is very challenging. Presentation of case: A 74-year-old patient presented with hemiparesis and decreased mentation. Head computed tomography (CT) revealed a heterogeneous density, multiseptated OCSDH. Initially, a burr-hole procedure was performed, but because hematoma evacuation was difficult, the procedure was converted to a craniotomy. Biopsy showed an organized hematoma, and culture of the excised lesion showed no growth. The patient initially had significant neurologic improvement, but later he developed a fatal chest infection. Discussion: Differentiating chronic subdural hematoma from OCSDH can be difficult because of striking clinical and imaging similarities. The intraoperative findings in patients with OCSDH are predominantly solid lesions. The literature on the management of OCSDH is scarce. Conclusion: OCSDH presents significant diagnostic and surgical challenges, particularly in resource-limited settings. Multiple septations on the preoperative CT should alert clinicians to the possibility of an organized hematoma, even when calcification is absent. Moreover, we, the authors, hypothesize that haphazard heterogeneity and the absence of a gravity-dependent density gradation may also suggest OCSDH, although this requires validation in future studies. When preoperative diagnostic uncertainty exists, initiating treatment with a burr hole is a practical diagnostic step. However, surgeons must recognize the key intraoperative signs of OCSDH, such as a non-suckable solid matrix and thick membranes that render burr-hole drainage ineffective, and immediately convert the procedure into craniotomy for direct excision and decompression. Incorporating this conversion possibility into preoperative patient and family counseling is essential.